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A SIMPLE TEST FOR LATENT JAUNDICE
1237 about 5 c.cm. of the medium is introduced and to the disposition of the X ray plant. The transit will be found that this runs directly into the middle nasal method recently described by Forestier and lobe. Again the patient is returned to the semi- ! Leroux 3 is much simpler but less certain, though recumbent position, but this time lying completely good results in filling the upper lobe are claimed. on the side that is being filled, and the remaining The other method in common use, transglottic few c.cm. injected. This last portion runs down the injection with a laryngeal syringe, is the most difficult lateral wall of the trachea and main bronchus and for complete bronchography because of the dexterity enters the orifice of the upper lobe bronchus by required for injecting oil when the patient is in the gravity, but, as the left upper lobe bronchus arises recumbent lateral position. rather more anteriorly, it is advisable to have the Whatever the method of injecting the opaque patient slightly inclined to the prone position to medium employed however-and no doubt each will make more certain of it when filling this side. The prefer that to which he is accustomed-the positions oil having been injected and having already comadopted for filling individual lobes will be the same, menced to nil the axillary part of the upper lobe, as should by now be evident. The superiority of the the apical and pectoral divisions are nlled most technique described lies, not in its absolute certainty, reliably by turning the patient almost completely for no method can have this, but in the principle on his face and tilting the head down or the feet that by its calculated completeness it reduces error up. The filling of the one side is then complete and to a minimum. It will readily be understood that films are taken as described. the neurotic patient and the patient who coughs will defeat even the most painstaking and that a dose of opium preceding the manoeuvres is still our best antidote for both. Care must be taken, too, that the oil is at a suitable temperature, for if too hot it will run rapidly into the alveoli and obscure the bronchograms, and iftoo cold it will not reach the lesser bronchi. Children under a general anaesthetic present constant difficulty in posturing, but with a little practice a fair attempt at the one-stage technique may be made ; the middle lobe is sometimes filled more easily in the prone position, the upright posture being difficult to accomplish.
abundantly
METHODS OF INTRODUCING OPAQUE MEDIA
It is outside the scope of this paper to enter into full discussion on the vexed question as to which is the best method of introducing iodised oil into the bronchi. I prefer the usual cricothyroid route, which possesses only one disadvantage in connexion with the methods described-namely, that it is necessary to remove the needle during the filling of the upper lobe, thus necessitating its reinsertion if it is desired to nil the other side at the same session. In practice this is of no importance as the area is already anaesthetised and no added discomfort is caused to the patient. The nasal catheter method is perhaps preferable in some ways, not having this disadvantage, but on the other hand, to obtain full benefit from the procedure, it is advisable to watch the progress of the opaque oil under the screen and yet to be able to take a radiogram at suitable intervals, a feat which is not possible in many hospitals owing a
efforts,
My thanks are due to Mr. H. P. Nelson and Dr. Lee Lander for some suggestions about the one-stage technique described. REFERENCES
1. Scadding, J. G. : Brit. Med. Jour., 1934, ii., 1147. 2. Nelson, H. P. : Ibid., 1934, ii., 251. 3. Forestier, J., and Leroux, L. : Radiology, 1935, xxiv., 743.
CLINICAL AND LABORATORY NOTES A SIMPLE TEST FOR LATENT JAUNDICE BY H. S. LATE
HOUSE
BRODRIBB, B.M Oxon.
PHYSICIAN, ST. BARTHOLOMEW’S HOSPITAL ;
E. R. CULLINAN, ASSISTANT
PHYSICIAN,
M.D., F.R.C.P.
ST.
AND
Lond.
BARTHOLOMEW’S HOSPITAL ;
PHYSICIAN, WOOLWICH MEMORIAL HOSPITAL
IN the
diagnosis
of
suspected hepatic
or
biliary
disease it is important to know whether the bilirubin in the blood is increased. Unfortunately, this fact can seldom be recognised by the observation of jaundice in the skin or sclerotics until the concentration of bilirubin has risen from the normal (between 01 and 0’4 mg. per cent.) to 2 mg. per cent. (4 units of van den Bergh) or over. The exact concentration can, of course, be determined by the van den Bergh reaction, but this is often impracticable at the bedside. 0. Klein1 (1931) showed that wheals produced in the skin of jaundiced patients by the intradermal injection of minute quantities of histamine became more deeply
yellow than the surrounding skin.
Further, he colour could be seen in histamine yellow wheals when the concentration of bilirubin in the blood, though raised, was insufficient to produce jaundice in the rest of the skin or in the sclerotics. He attributed this phenomenon to the abnormal permeability of the capillaries for bile-pigment caused found that
a
1 Klin. Woch., 1931, x., 2032.
by the histamine, allowing the pigment to
escape and concentrate in the wheal. We have carried out this test on a number of cases and have found it to be a simple and reliable method of determining qualitatively the presence of latent jaundice. It is useful particularly as a clinical test, even if only as a preliminary to more complicated quantitative estimations. In cases of obstruction of the biliary tract or of damage to the liver cells the test is constantly positive when the concentration of bilirubin in the blood has risen above 0’5 mg. per cent. (1 unit of van den Bergh). In cases of hsemolytic jaundice the test is not positive until the concentration of bilirubin is rather greater (between 1’1and 1’4 mg. per cent.). This conforms with the clinical observation that in cases of haemolytic jaundice the yellow colour is not seen in the skin or sclerotics until the concentration of bilirubin has reached a higher figure than in cases of obstructive jaundice. TECHNIQUE
patient is placed in good daylight. Direct sunlight and artificial light are unsatisfactory. A small area of skin free, if possible, from sunburn and freckles is cleaned with spirit. The most suitable site is usually on the upper arm or on the back. One minim of a sterile solution containing 0-1mg. of histamine is injected intradermally into this area by means of a fine hypodermic or special intradermal needle. It is essential that the injection should be made intradermally and if it is done correctly a small The
.
1238 white circumscribed bleb is produced in the skin. The dose of histamine should not exceed 0*1ing. as larger amounts may produce an unpleasant reaction. The preparation used by us was histamine acid phosphate (Burroughs, Wellcome and Co.): 0*3 mg. of this salt is equivalent to 0’1 mg. of histamine. Within about five minutes a circular wheal, surrounded by an erythematous zone, develops in the region of the injection. This may also extend in a linear fashion for a short distance along the neighbouring lymphatics. In 10 to 20 minutes the wheal reaches its maximum size ; any moisture on the surface of the wheal should be wiped away before it is examined. If the test is positive the wheal is definitely yellow when compared with the normal skin outside the erythematous zone. This yellow colour is much enhanced by the pressure of a glass slide or by placing the two thumbs on each side of the wheal and stretching it between them, the observation being made at If there is any doubt as to whether the arms length. wheal is yellow or not, the test is regarded as negative. When the patient is already jaundiced, the colour of the wheal will be a deeper yellow than that of the adjacent skin, but in such cases the test is obviously
LITHOPÆDION IN A CENTENARIAN BY LOH GUAN LYE, L.M.S. OF THE GENERAL
HOSPITAL, SINGAPORE
of lithopsedion have been reported 340 years.1 The length of time during which the one here reported was retained makes the present case of unusual interest. A wizened old Chinese woman came to the Singapore General Hospital in March, 1936, complaining of abdominal ABOUT 212
cases
during the last
She said that this arose from a lump that had been present in the abdomen for 60 years but had given no symptoms until three months previously. Asked about the lump, she said that it was a baby, and she gave the following history. Menstruation commenced when she
pain.
unnecessary.22
Table
Showing
Results
of
the Test
Radiogram of Iithopsedion : showing skull (indicated by arrows) and vertebree. 13 years of age. She was married at 18. Her first pregnancy occurred when she was 30, and a healthy female child was born after a normal labour. At 40 she had a second pregnancy which proceeded normally until near full term, when severe abdominal pains occurred. These she thought were labour pains, although very intense. A Malay woman was called in to massage the abdomen. after which all foetal movements ceased and no child was born. Pain disappeared within a month. Menstruation started again a year later, and continued regularly until the age of 70. Examination showed a lax abdominal wall, through which a hard, nodular, tender mass could be felt. This lay near the centre of the abdomen, but was freely movable through a range allowed by the pedicle which connected it to the pelvis. No further information could be gained by examination of the stenosed vagina or of the rectum. The radiogram shows a rounded shadow in which the skull and vertebral column of a fcetus are readily recognised. Her pain was evidently not severe, and after reassurance she went home. There must remain a little doubt as to the exact age of the mother and of the foetus. The patient maintains that she did not reach the menopause until 30 years ago, when she was 70. This raises a suspicion that she may have exaggerated her age, and there is It is suggested no birth certificate to confirm it. was
RESULTS
The results of the test in a number of cases are shown in the accompanying Table. The obstructive and hepatogenous group includes such cases as cholelithiasis, catarrhal jaundice, and toxic jaundice. It will be seen that the threshold for this group is clearly defined at 0-5 mg. per cent. of serum bilirubin (1’ unit indirect van den Bergh). The hsemolytic group includes such cases as acholuric jaundice and pernicious anaemia. The threshold for this group is higher and lies somewhere between 1-1and 1-4 mg. per cent. serum bilirubin (2-2 to 2-8 units indirect van den Bergh). We wish to thank the members of the department of chemical pathology at St. Bartholomew’s Hospital for the van den Bergh estimations. 2
The presence of abnormal pigmen’s in the serum, other than bilirubin, is very uncommon ; but it might be expected that the colour of such pigments would concentrate in a histamine skin wheal. We found this in a case of carotinæmia in which the concentration of bilirubin was normal.
that the radiographic shadow is the result of an ectopic pregnancy that went to term some 60 years 1 Bland, P. B., Goldstein, L., and Bolton, W. W. : Surg. Gyn., and Obst., 1933, lvi., 939.
abundantly
METHODS OF INTRODUCING OPAQUE MEDIA
It is outside the scope of this paper to enter into full discussion on the vexed question as to which is the best method of introducing iodised oil into the bronchi. I prefer the usual cricothyroid route, which possesses only one disadvantage in connexion with the methods described-namely, that it is necessary to remove the needle during the filling of the upper lobe, thus necessitating its reinsertion if it is desired to nil the other side at the same session. In practice this is of no importance as the area is already anaesthetised and no added discomfort is caused to the patient. The nasal catheter method is perhaps preferable in some ways, not having this disadvantage, but on the other hand, to obtain full benefit from the procedure, it is advisable to watch the progress of the opaque oil under the screen and yet to be able to take a radiogram at suitable intervals, a feat which is not possible in many hospitals owing a
efforts,
My thanks are due to Mr. H. P. Nelson and Dr. Lee Lander for some suggestions about the one-stage technique described. REFERENCES
1. Scadding, J. G. : Brit. Med. Jour., 1934, ii., 1147. 2. Nelson, H. P. : Ibid., 1934, ii., 251. 3. Forestier, J., and Leroux, L. : Radiology, 1935, xxiv., 743.
CLINICAL AND LABORATORY NOTES A SIMPLE TEST FOR LATENT JAUNDICE BY H. S. LATE
HOUSE
BRODRIBB, B.M Oxon.
PHYSICIAN, ST. BARTHOLOMEW’S HOSPITAL ;
E. R. CULLINAN, ASSISTANT
PHYSICIAN,
M.D., F.R.C.P.
ST.
AND
Lond.
BARTHOLOMEW’S HOSPITAL ;
PHYSICIAN, WOOLWICH MEMORIAL HOSPITAL
IN the
diagnosis
of
suspected hepatic
or
biliary
disease it is important to know whether the bilirubin in the blood is increased. Unfortunately, this fact can seldom be recognised by the observation of jaundice in the skin or sclerotics until the concentration of bilirubin has risen from the normal (between 01 and 0’4 mg. per cent.) to 2 mg. per cent. (4 units of van den Bergh) or over. The exact concentration can, of course, be determined by the van den Bergh reaction, but this is often impracticable at the bedside. 0. Klein1 (1931) showed that wheals produced in the skin of jaundiced patients by the intradermal injection of minute quantities of histamine became more deeply
yellow than the surrounding skin.
Further, he colour could be seen in histamine yellow wheals when the concentration of bilirubin in the blood, though raised, was insufficient to produce jaundice in the rest of the skin or in the sclerotics. He attributed this phenomenon to the abnormal permeability of the capillaries for bile-pigment caused found that
a
1 Klin. Woch., 1931, x., 2032.
by the histamine, allowing the pigment to
escape and concentrate in the wheal. We have carried out this test on a number of cases and have found it to be a simple and reliable method of determining qualitatively the presence of latent jaundice. It is useful particularly as a clinical test, even if only as a preliminary to more complicated quantitative estimations. In cases of obstruction of the biliary tract or of damage to the liver cells the test is constantly positive when the concentration of bilirubin in the blood has risen above 0’5 mg. per cent. (1 unit of van den Bergh). In cases of hsemolytic jaundice the test is not positive until the concentration of bilirubin is rather greater (between 1’1and 1’4 mg. per cent.). This conforms with the clinical observation that in cases of haemolytic jaundice the yellow colour is not seen in the skin or sclerotics until the concentration of bilirubin has reached a higher figure than in cases of obstructive jaundice. TECHNIQUE
patient is placed in good daylight. Direct sunlight and artificial light are unsatisfactory. A small area of skin free, if possible, from sunburn and freckles is cleaned with spirit. The most suitable site is usually on the upper arm or on the back. One minim of a sterile solution containing 0-1mg. of histamine is injected intradermally into this area by means of a fine hypodermic or special intradermal needle. It is essential that the injection should be made intradermally and if it is done correctly a small The
.
1238 white circumscribed bleb is produced in the skin. The dose of histamine should not exceed 0*1ing. as larger amounts may produce an unpleasant reaction. The preparation used by us was histamine acid phosphate (Burroughs, Wellcome and Co.): 0*3 mg. of this salt is equivalent to 0’1 mg. of histamine. Within about five minutes a circular wheal, surrounded by an erythematous zone, develops in the region of the injection. This may also extend in a linear fashion for a short distance along the neighbouring lymphatics. In 10 to 20 minutes the wheal reaches its maximum size ; any moisture on the surface of the wheal should be wiped away before it is examined. If the test is positive the wheal is definitely yellow when compared with the normal skin outside the erythematous zone. This yellow colour is much enhanced by the pressure of a glass slide or by placing the two thumbs on each side of the wheal and stretching it between them, the observation being made at If there is any doubt as to whether the arms length. wheal is yellow or not, the test is regarded as negative. When the patient is already jaundiced, the colour of the wheal will be a deeper yellow than that of the adjacent skin, but in such cases the test is obviously
LITHOPÆDION IN A CENTENARIAN BY LOH GUAN LYE, L.M.S. OF THE GENERAL
HOSPITAL, SINGAPORE
of lithopsedion have been reported 340 years.1 The length of time during which the one here reported was retained makes the present case of unusual interest. A wizened old Chinese woman came to the Singapore General Hospital in March, 1936, complaining of abdominal ABOUT 212
cases
during the last
She said that this arose from a lump that had been present in the abdomen for 60 years but had given no symptoms until three months previously. Asked about the lump, she said that it was a baby, and she gave the following history. Menstruation commenced when she
pain.
unnecessary.22
Table
Showing
Results
of
the Test
Radiogram of Iithopsedion : showing skull (indicated by arrows) and vertebree. 13 years of age. She was married at 18. Her first pregnancy occurred when she was 30, and a healthy female child was born after a normal labour. At 40 she had a second pregnancy which proceeded normally until near full term, when severe abdominal pains occurred. These she thought were labour pains, although very intense. A Malay woman was called in to massage the abdomen. after which all foetal movements ceased and no child was born. Pain disappeared within a month. Menstruation started again a year later, and continued regularly until the age of 70. Examination showed a lax abdominal wall, through which a hard, nodular, tender mass could be felt. This lay near the centre of the abdomen, but was freely movable through a range allowed by the pedicle which connected it to the pelvis. No further information could be gained by examination of the stenosed vagina or of the rectum. The radiogram shows a rounded shadow in which the skull and vertebral column of a fcetus are readily recognised. Her pain was evidently not severe, and after reassurance she went home. There must remain a little doubt as to the exact age of the mother and of the foetus. The patient maintains that she did not reach the menopause until 30 years ago, when she was 70. This raises a suspicion that she may have exaggerated her age, and there is It is suggested no birth certificate to confirm it. was
RESULTS
The results of the test in a number of cases are shown in the accompanying Table. The obstructive and hepatogenous group includes such cases as cholelithiasis, catarrhal jaundice, and toxic jaundice. It will be seen that the threshold for this group is clearly defined at 0-5 mg. per cent. of serum bilirubin (1’ unit indirect van den Bergh). The hsemolytic group includes such cases as acholuric jaundice and pernicious anaemia. The threshold for this group is higher and lies somewhere between 1-1and 1-4 mg. per cent. serum bilirubin (2-2 to 2-8 units indirect van den Bergh). We wish to thank the members of the department of chemical pathology at St. Bartholomew’s Hospital for the van den Bergh estimations. 2
The presence of abnormal pigmen’s in the serum, other than bilirubin, is very uncommon ; but it might be expected that the colour of such pigments would concentrate in a histamine skin wheal. We found this in a case of carotinæmia in which the concentration of bilirubin was normal.
that the radiographic shadow is the result of an ectopic pregnancy that went to term some 60 years 1 Bland, P. B., Goldstein, L., and Bolton, W. W. : Surg. Gyn., and Obst., 1933, lvi., 939.